A Qualitative Study of the
Electronic Medical Record
Lisa Grabenbauer, M.S.
Anne Skinner, M.S.
John R. Windle M.D.
University of Nebraska Medical Center
Disclosures
John Windle-No conflict of interest
Anne Skinner-No conflict of interest
Lisa Grabenbauer-No conflict of interest
Research Overview
Objective
• Explore the sources of resistance to EMR
adoption by the physician community
• Examine physicians’ perspective on the
benefits and limitations of current Electronic
Medical Records (EMR)
Context
• Compare environments and culture
• Veteran’s Administration Medical Center
(VAMC) paperless system (VistA and CPRS)
• The Nebraska Medical Center’s (TNMC) GE
Centricity Enterprise system
Study Design
Data
Collection
• Focus group format
• Participants included physicians who practice at both
institutions
• Open-ended questions about interaction with respective EMR
systems and the systems perceived benefits and limitations
• Conducted in November and December 2008
Analysis
• Group proceedings audio-recorded and transcribed
• Data elements systematically coded and analyzed using NVivo
v8.0 software
• Iterative identification of themes unique and similar across all
groups
• Themes revised until consensus achieved
A Qualitative Study of the Electronic Medical Record:
The Quotes
r
Findings
Two major •Workflow
themes •Communication
Workflow
Benefit
Cost
Impact on
Patient Care
•Availability of patient data both spatially and temporally
•VA system more comprehensive
•University system better organized
•Templated notes save time and improve documentation
•Time consuming retrieval of select patient information
•VA system very difficult to search with significant reduncency
•University system less comprehensive and required searching several disconnected data sources.
•Templated notes decrease readability and comprehension
•Too much “copying and pasting” in the VAMC’s EMR
•Availability at point of care
•Information input and retrieval overhead reduces time with patient
Communication
Benefit
Cost
Impact on
Patient Care
• Ability to share patient-centric information
• Other providers
• Patients
• Reduced direct communication between health care
providers
• No transparency between VAMC and TNMC EMR systems
or external EMR
• Patient access to information
• Redundancy creates frustration
Outcomes and Research
Benefit
• VA system is comprehensive and can link across the country
• Reliable data at the point-of-care can improve outcomes
Cost
• In the VAMC data entry is driven by and through physicians at
the expense of patient care
• TNMC’s EMR doesn’t support structured data
Impact on
Patient Care
• The potential to improve patient outcomes holds great promise
• That promise is not easily recognized in either current system.
Education and Learning
Benefit
• Both faculty and housestaff (fellows and residents) were
positive about the impact of web-based educational content
such as Up-to-date and Google scholar.
• Housestaff were more positive about its impact than faculty.
Cost
• The positively cited materials were outside of either EMR
• Internal alerts were viewed “fairly useless” and in many cases
forced workarounds.
Impact on
Patient Care
• Availability at point of care, just-in-time learning
• Alerts require an over-ride to prescribe, this was perceived as
larger problem at the VAMC than NMC
EMR Comparison
TNMC
VAMC
Strength
Logically organized
Comprehensive
Weakness
Limited information in
primary EMR
Not intuitive
Labor intensive
Meets physician needs
Too many different
clinical databases that
don’t work together
Too much information
repeated
NO
NO
Conclusions
Physicians
optimistic about
EMR potential for
systematic
collection of data
to improve patient
care
Current EMR
frustrates physician
with cumbersome
interfaces and
processes
EMR must provide seamless and flexible interfaces across
system boundaries, for data input as well as data retrieval.
They should facilitate patient and team interactions, not
inhibit them.